<head>
<style type="text/css">
 .link{
    background-color:66cdcc ;
  	-moz-border-radius: 15px;
  	-webkit-border-radius: 15px;
  	padding: 2px;

}
</style>
</head>
<form name="form" method="post">
	<table align="center" style="background-color: 414141">
		<tr>
			<td align="left">
				<span style="background-color: 66cdcc;color: white;">- Request More Information</span>
			</td>		
		</tr>
		<tr>
			<td align="left">
				<input type="text" value="FirstName">
			</td>
		</tr>
		<tr>
			<td align="left">
				<input type="text" value="LastName">
			</td>
		</tr>
		<tr>
			<td align="left">
				<input type="text" value="Phone">
			</td>
		</tr>
		<tr>
			<td align="left">
				<input type="text" value="Email Address">
			</td>
		</tr>						
		<tr>
			<td align="left">
				<textarea style="width: 155px;height: 50px">Comments</textarea>
			</td>
		</tr>		
		<tr>
			<td align="left">
				<span class="link"><a href="#"><b style="color: 414141">Submit Your Request</b></a></span>
			</td>
		</tr>				
	</table>
</form>